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Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes.
Arch Intern Med. 2007 May 28; 167(10):1009-16.AI

Abstract

BACKGROUND

Randomized clinical trials have established the efficacy of an early invasive management strategy for high-risk non-ST elevation acute coronary syndromes (ACSs). We examined the use of in-hospital cardiac catheterization and medications in relation to risk across the broad spectrum of non-ST elevation ACSs.

METHODS

We evaluated 4414 patients with non-ST elevation ACSs in the prospective, multicenter, Canadian ACS 1 (September 1, 1999-June 30, 2001) and ACS 2 (October 1, 2002-December 31, 2003) Registries. Patients were stratified into low-, intermediate-, and high-risk groups based on tertiles of the calculated Global Registry of Acute Coronary Events risk score (a validated predictor of in-hospital mortality).

RESULTS

Although in-hospital mortality rates were similar, the in-hospital use of cardiac catheterization increased significantly over time (38.8% in the ACS 1 Registry vs 63.5% in the ACS 2 Registry; P<.001). The rates of cardiac catheterization in the low-, intermediate-, and high-risk groups were 48.0%, 41.1%, and 27.3% in the ACS 1 Registry, and 73.8%, 66.9%, and 49.7% in the ACS 2 Registry, respectively (P<.001 for trend for both). After adjusting for other confounders, intermediate-risk (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90; P<.001) and high-risk (adjusted odds ratio, 0.35; 95% confidence interval, 0.28-0.45; P<.001) patients remained less likely to undergo cardiac catheterization compared with low-risk patients. Furthermore, there existed a similar inverse relationship between risk and the use of in-hospital revascularization and medications.

CONCLUSIONS

Despite temporal increases in the use of cardiac catheterization and revascularization in the management of non-ST elevation ACSs, evidence-based invasive and pharmacological therapies remain paradoxically targeted toward low-risk patients. Strategies to eliminate this treatment-risk paradox must be implemented to fully realize the benefits and optimize the cost-effectiveness of invasive management.

Authors+Show Affiliations

Division of Cardiology, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada M5B 1W8.No affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info availableNo affiliation info available

Pub Type(s)

Journal Article
Research Support, Non-U.S. Gov't

Language

eng

PubMed ID

17533203

Citation

Yan, Andrew T., et al. "Management Patterns in Relation to Risk Stratification Among Patients With non-ST Elevation Acute Coronary Syndromes." Archives of Internal Medicine, vol. 167, no. 10, 2007, pp. 1009-16.
Yan AT, Yan RT, Tan M, et al. Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes. Arch Intern Med. 2007;167(10):1009-16.
Yan, A. T., Yan, R. T., Tan, M., Fung, A., Cohen, E. A., Fitchett, D. H., Langer, A., & Goodman, S. G. (2007). Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes. Archives of Internal Medicine, 167(10), 1009-16.
Yan AT, et al. Management Patterns in Relation to Risk Stratification Among Patients With non-ST Elevation Acute Coronary Syndromes. Arch Intern Med. 2007 May 28;167(10):1009-16. PubMed PMID: 17533203.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Management patterns in relation to risk stratification among patients with non-ST elevation acute coronary syndromes. AU - Yan,Andrew T, AU - Yan,Raymond T, AU - Tan,Mary, AU - Fung,Anthony, AU - Cohen,Eric A, AU - Fitchett,David H, AU - Langer,Anatoly, AU - Goodman,Shaun G, AU - ,, PY - 2007/5/30/pubmed PY - 2007/6/30/medline PY - 2007/5/30/entrez SP - 1009 EP - 16 JF - Archives of internal medicine JO - Arch Intern Med VL - 167 IS - 10 N2 - BACKGROUND: Randomized clinical trials have established the efficacy of an early invasive management strategy for high-risk non-ST elevation acute coronary syndromes (ACSs). We examined the use of in-hospital cardiac catheterization and medications in relation to risk across the broad spectrum of non-ST elevation ACSs. METHODS: We evaluated 4414 patients with non-ST elevation ACSs in the prospective, multicenter, Canadian ACS 1 (September 1, 1999-June 30, 2001) and ACS 2 (October 1, 2002-December 31, 2003) Registries. Patients were stratified into low-, intermediate-, and high-risk groups based on tertiles of the calculated Global Registry of Acute Coronary Events risk score (a validated predictor of in-hospital mortality). RESULTS: Although in-hospital mortality rates were similar, the in-hospital use of cardiac catheterization increased significantly over time (38.8% in the ACS 1 Registry vs 63.5% in the ACS 2 Registry; P<.001). The rates of cardiac catheterization in the low-, intermediate-, and high-risk groups were 48.0%, 41.1%, and 27.3% in the ACS 1 Registry, and 73.8%, 66.9%, and 49.7% in the ACS 2 Registry, respectively (P<.001 for trend for both). After adjusting for other confounders, intermediate-risk (adjusted odds ratio, 0.75; 95% confidence interval, 0.63-0.90; P<.001) and high-risk (adjusted odds ratio, 0.35; 95% confidence interval, 0.28-0.45; P<.001) patients remained less likely to undergo cardiac catheterization compared with low-risk patients. Furthermore, there existed a similar inverse relationship between risk and the use of in-hospital revascularization and medications. CONCLUSIONS: Despite temporal increases in the use of cardiac catheterization and revascularization in the management of non-ST elevation ACSs, evidence-based invasive and pharmacological therapies remain paradoxically targeted toward low-risk patients. Strategies to eliminate this treatment-risk paradox must be implemented to fully realize the benefits and optimize the cost-effectiveness of invasive management. SN - 0003-9926 UR - https://www.unboundmedicine.com/medline/citation/17533203/Management_patterns_in_relation_to_risk_stratification_among_patients_with_non_ST_elevation_acute_coronary_syndromes_ L2 - https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/archinte.167.10.1009 DB - PRIME DP - Unbound Medicine ER -